Adventitious Breath Sounds in the Pediatric Patient Shailendra Das, DO Assistant Professor Department of Pediatrics Baylor College of Medicine
Pediatrics Objectives
• Classify various breath sounds by timing, quality, and location • Provide a differential diagnosis based on specific adventitious sound • Discuss clues to help identify specific diagnosis • Identify patients that need further workup, referral, treatment
Page 2 Pediatrics xxx00.#####.ppt 4/10/19 10:33:45 AM Disclosures
• No financial disclosures
Page 3 Pediatrics xxx00.#####.ppt 4/10/19 10:33:45 AM A little about me…
• Born/raised in Houston • Aggie (whoop!!) • Pulmonary fellowship at TCH • Cook Children’s (2012-2014) • Back at TCH • Member of our Lung transplant and Aerodigestive teams
Page 4 Pediatrics xxx00.#####.ppt 4/10/19 10:33:46 AM Normal pulmonary physical exam •Consists of four parts: -Inspection -Ascultation -Percussion -Palpation
•Extrapulmonary exam: -Nasal flaring -Clubbing -Cyanosis
Page 5 Pediatrics xxx00.#####.ppt 4/10/19 10:33:47 AM Pulmonary exam--Ascultation
• Five lobes usually (LUL, LLL, RUL, RML, and RLL) - Lingula—part of the left upper lobe
• Must account for upper airway, central (conducting) airways as part of exam
Page 6 Pediatrics xxx00.#####.ppt 4/10/19 10:33:47 AM Factors important in distinguishing sounds and creating differential diagnosis
• Location • Timing - Inspiratory, expiratory, or both - Same cycle vs varying cycle of breathing
• Monophonic vs polyphonic • Low pitch vs high pitch
Page 7 Pediatrics xxx00.#####.ppt 4/10/19 10:33:48 AM Noisy breathing
• Wheezing - Low pitch wheeze = rhonchi • Stridor • Stertor • Crackles (rales) • Grunting
Page 8 Pediatrics xxx00.#####.ppt 4/10/19 10:33:48 AM Localizing sounds: Where is the obstruction?
Page 9 Pediatrics xxx00.#####.ppt 4/10/19 10:33:49 AM Localizing sounds
• Inspiratory sounds= EXTRAthoracic obstruction - Eg primarily stridor
• Expiratory sounds=INTRAthoracic obstruction - Eg primarily wheezing
Page 10 Pediatrics xxx00.#####.ppt 4/10/19 10:33:50 AM Normal breath sounds
https://dev- journals2013.lww.com/nursingmadeincrediblyeasy/Citation/2007/01000/Every_breath_you_take__Making_sensePage 11 Pediatrics _of_breath.2.aspx xxx00.#####.ppt 4/10/19 10:33:50 AM Bronchial breath sounds
• Also known as tubular breath sounds - Sound moving through a tube or straw
• NORMAL when heard over the manubrium
• NOT NORMAL when heard anywhere else - ***sometimes heard in peripheral lung fields—importantly, in consolidation
Page 12 Pediatrics xxx00.#####.ppt 4/10/19 10:33:51 AM Adventitious sounds-- wheezing
Pediatrics What is “wheezing?”
• Defined as a continuous musical expiratory sound caused by INTRAthoracic airway obstruction • Produced by oscillation of opposing walls of an airway that are narrowed to the point of closure
Weinberger M and Abu-Hasan M. Pediatrics 2007. Page 14 Pediatrics xxx00.#####.ppt 4/10/19 10:33:52 AM Reynolds C. British Journal of Hospital Medicine 2014. Page 15 Pediatrics xxx00.#####.ppt 4/10/19 10:33:52 AM All that wheezes is not asthma
Pediatrics What is “asthma”?
• Characterized by: - Hyperresponsiveness of the airways to various stimuli, leading to reversible airway obstruction - Airway obstruction result of bronchospasm and inflammation/mucosal edema - Recurrent wheezing--POLYPHONIC - Reversibility with treatment a key component
Page 17 Pediatrics xxx00.#####.ppt 4/10/19 10:33:57 AM Wheezing—exam findings
• Asthma/Lower airway obstruction: classically demonstrate high-pitched musical expiratory sounds, varying in tone and timing (“polyphonic”)
• Localized bronchial narrowing: single pitch, begins/ends at same time (“monophonic”)
Page 18 Pediatrics xxx00.#####.ppt 4/10/19 10:33:58 AM Therapeutics
• Bronchodilator therapy in asthma— - Helps relax smooth muscle, with immediate goal of relieving small airway obstruction • However, in other diseases, bronchodilators may have no effect, or in the case of airway malacia, worsen the problem
Page 19 Pediatrics xxx00.#####.ppt 4/10/19 10:33:58 AM What else could it be? When symptoms persist despite conventional asthma therapy, or when classic symptoms do not exist, one must consider other diagnoses
Page 20 Pediatrics xxx00.#####.ppt 4/10/19 10:33:59 AM Differential diagnosis of wheezing
• Asthma • Bronchiolitis • GER • Chronic aspiration • Tracheomalacia/Bronchomalacia • Foreign body aspiration • Cystic fibrosis • Primary ciliary dyskinesia • Immunodeficiency • Cardiac disease/Vascular compression • Bronchiolitis obliterans
Page 21 Pediatrics xxx00.#####.ppt 4/10/19 10:33:59 AM Findings to suggest other etiologies
History Exam and Other findings
•Onset early in infancy •Clubbing •Neurologic dysfunction •Murmur •Wheezing with/after feeds •Stridor or crackles on exam •Diarrhea •Focal signs-- exam/CXR •Poor weight gain •Recurrent/prolonged cyanosis or hypoxemia •O2 requirement >1 week after onset •Anemia •Irreversible airflow obstruction
Fakhoury KF. Up to date 2012. Page 22 Pediatrics xxx00.#####.ppt 4/10/19 10:34:00 AM Differential diagnosis of wheezing • Vocal cord dysfunction (paradoxical vocal fold movement) - Occurs at the onset of activity, “type A”, difficulty getting air in - Can co-exist with asthma
• Chronic aspiration - Daily wheezing/choking/coughing with feeds
• Tracheomalacia/Bronchomalacia - Monophonic low pitch wheeze, can get worse with Albuterol; barky cough - H/o cardiac disease, genetic mutation, or TEF
Page 23 Pediatrics xxx00.#####.ppt 4/10/19 10:34:01 AM Differential diagnosis of wheezing
• Foreign body aspiration - Acute onset wheezing/cough—Usually focal wheezing - H/o choking incident • Cystic fibrosis - Recurrent purulent cough, poor weight gain, clubbing • Primary ciliary dyskinesia - Recurrent ear infections, daily purulent rhinitis • Bronchiolitis obliterans - H/o infection (esp Adenovirus), with onset of dyspnea 4-8 weeks later, unrelenting, wheezing not improved by Albuterol
Page 24 Pediatrics xxx00.#####.ppt 4/10/19 10:34:01 AM Crackles
Page 25 Pediatrics xxx00.#####.ppt 4/10/19 10:34:02 AM Crackles
• “velcro fastening” “rubbing a strand of hair between two fingers close to your ears” • Relates to opening of airways that are collapsed, or filled with pus/fluid • Can be heard throughout respiratory cycle
Page 26 Pediatrics xxx00.#####.ppt 4/10/19 10:34:02 AM Crackles
• Fine crackles - Soft, higher pitch, brief - Sounds similar to cellophane being crumpled - Usually associated with interstitial process • Coarse crackles - Louder, longer, low pitch - Sounds similar to running a hair strand between two fingers - Associated with airway/alveolar disease (atelectasis, bronchiectasis)
Page 27 Pediatrics xxx00.#####.ppt 4/10/19 10:34:03 AM Page 28 Pediatrics xxx00.#####.ppt 4/10/19 10:34:04 AM Crackles—Differential diagnosis
• Fine crackles - Pulmonary edema - Lung fibrosis - Interstitial lung disease
• Coarse crackles - Bronchiectasis - Pneumonia - Atelectasis
Page 29 Pediatrics xxx00.#####.ppt 4/10/19 10:34:04 AM Stridor
• High-pitched turbulent sound • Can be inspiratory, expiratory, or bi-phasic • Most commonly inspiratory
Page 30 Pediatrics xxx00.#####.ppt 4/10/19 10:34:05 AM Causes of stridor
• Layngomalacia • Croup • Epiglottitis • Vocal fold paralysis • Subglottic stenosis • Vascular ring • Glottic web • Papillomas
Page 31 Pediatrics xxx00.#####.ppt 4/10/19 10:34:05 AM Laryngomalacia
• Most common cause of stridor in infants • Congenital softening of the laryngeal tissues (results in omega shape epiglottis) • Usually benign (~90% of the time)
www.chop.edu
Page 32 Pediatrics xxx00.#####.ppt 4/10/19 10:34:06 AM Laryngomalacia—the other 10%
• Things to watch out for/warning signs for parents: - Cyanotic events - Apneic events (ALTE/BRUE) - Failure to thrive - Significant work of breathing (retractions, nasal flaring) - Choking with feeds • Surgical management possible (Supraglottoplasty)
Page 33 Pediatrics xxx00.#####.ppt 4/10/19 10:34:07 AM Stridor and associated findings
Associated findings Most common Diagnosis(es) Stridor worse when supine, worse with Laryngomalacia crying Worse with feeding Vascular compression, tracheomalacia Choking Foreign body, tracheo-esophageal fistula Brassy cough Croup Hoarseness, muffled cry Vocal cord paralysis Anxiety (older child) Vocal cord dysfunction (better known as paradoxical vocal fold movement)
Page 34 Pediatrics xxx00.#####.ppt 4/10/19 10:34:07 AM www.aafp.org Page 35 Pediatrics xxx00.#####.ppt 4/10/19 10:34:08 AM Biphasic stridor
• Indicates glottic or subglottic narrowing • Etiologies include: - Croup - Vascular ring - Subglottic stenosis - Vocal cord paresis - Tracheal mass
• NOT normal
Page 36 Pediatrics xxx00.#####.ppt 4/10/19 10:34:09 AM Videos--stridor
• Laryngomalacia - https://www.youtube.com/watch?v=XTyNhbJAkwQ
• Biphasic stridor from croup - https://www.youtube.com/watch?v=nwYHryiy3HY
Page 37 Pediatrics xxx00.#####.ppt 4/10/19 10:34:09 AM Ewing C et al. Pediatrics &Child Health 2017. Page 38 Pediatrics xxx00.#####.ppt 4/10/19 10:34:10 AM Other sounds
• Grunting: deep sound heard during expiration, caused when a child exhales against a partially closed glottis to try and keep the bronchioles open to prevent alveolar closure; can be late sign of respiratory distress
• Stertor: “awake snoring”—results from vibration of the pharyngeal tissues due to obstruction of the upper airway
Page 39 Pediatrics xxx00.#####.ppt 4/10/19 10:34:10 AM When to refer/Consider urgent management
• Stridor - Apneic/Cyanotic events, choking with feeds, failure to thrive - Biphasic stridor - Workup can include: CXR (croup), esophagram or CT angio; laryngoscopy and/or bronchoscopy • Wheezing - When symptoms don’t improve with bronchodilator - Monophonic or localized wheezing
• Crackles (if chronic, CXR not conclusive of pneumonia/atelectasis)
Page 40 Pediatrics xxx00.#####.ppt 4/10/19 10:34:11 AM Question 1
• You are evaluating a 3 year old child in your clinic with cough for 1 week. On exam, you hear wheezing, but only in the right lower lobe. The wheezing appears to have the same time in expiration with every breath. Of the choices, what is your next step in management?
- A. Administer bronchodilator (albuterol) therapy - B. Emergent referral to ENT for bronchoscopy - C. Swallow function study - D. Chest physiotherapy
Page 41 Pediatrics xxx00.#####.ppt 4/10/19 10:34:12 AM Question 2
• You are seeing a 2 month old for their checkup and vaccines. Mom notes her baby is having “abnormal breathing sounds” and fussiness. She describes a high pitch sound on inspiration, worse when the baby is fussy and hungry. It gets better when her child is held upright. She denies any cyanotic or apneic episodes, and you note the patient is >75%ile for weight. What is your best recommendation to mom? - A. ENT needs to do a surgical procedure to correct the issue - B. Reassure mom and observe - C. Start a trial of GER medication
Page 42 Pediatrics xxx00.#####.ppt 4/10/19 10:34:12 AM Question 3
• A 2 week infant is brought to your urgent care center for repeat episodes of spitting up/choking on feeds, along with noisy breathing. He has not yet regained his birth weight. On exam, you note biphasic stridor. Of the choices listed below, what is the most likely cause of this patient’s symptoms? - A. Asthma exacerbation - B. Laryngomalacia - C. Vascular ring - D. Paradoxical vocal fold movement
Page 43 Pediatrics xxx00.#####.ppt 4/10/19 10:34:13 AM https://medlineplus.gov/ency/article/007318.htm Osborne CM et al. Journal of Hospital Medicine 2014. Page 44 Pediatrics xxx00.#####.ppt 4/10/19 10:34:13 AM Take home points
• Adventitious breath sounds vary in timing, location, pitch/tone. Using these differences to classify helps obtain a more precise differential diagnosis. • Inspiratory sounds are caused by extrathoracic obstruction; expiratory sounds are caused by intrathoracic obstruction • All that wheezes is not asthma— using other clues may help lead to the alternative diagnosis • Know when to refer (to a pulmonologist, or ER setting) - …also know that it’s OK to refer
Page 45 Pediatrics xxx00.#####.ppt 4/10/19 10:34:14 AM Questions??
• **All sounds used in this presentation come from www.easyascultation.com
Page 46 Pediatrics xxx00.#####.ppt 4/10/19 10:34:15 AM